The Underlying Disease of a Medical Practice

 

I have experience with nearly all operational roles in a provider’s practice. I have been involved in almost every role in the medical office except for clinical. This has provided me with a unique understanding of the barriers and opportunities for patients and providers for the healthcare process. This experience has been my motivation to assist others in optimization, risk mitigation, and increased value driven patient care.

Timely and quality patient care is always the focus. However, there are numerous barriers and levels of friction that inhibit this. The adoption of software will not solve the issue. Integrated solutions augmented by subject matter experts are the differentiator to effectiveness and results.

The ability to increase financial and operational transparency is what is needed. To this point practices and services lines have simply “added FTEs” to the problem. Inadvertently this increased the degree of variability and the lack of variability that is needed for standardization, that results in more positive viability.

It’s not a perfect system but we can improve our efficiency.

What does your data show?

In our technology driven world we run on data. The world of healthcare Reimbursement is all data related. We do not want to ignore what the data is telling us. We are inundated with data, KPIs, dashboards etc. Without context. What are the baselines?

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Do you regularly check your common Denials?

Do you know your insurance payer mix and how your payments perform with each payer mix ?

Possibly, but is the data accurate? Is it prioritized? Is it actionable? Is it relational? Do you have accountability plans from the data?

Many come to our team to help them understand their data, and then we walk through a systematic approach to fix the areas internally that are causing the systemic disease in a practice revenue.

Process improvement requires a unique combination of technology, data, expertise and training. We bring this to you and your practice with decades of proven experience.

Don’t use a Band-Aide

Fast and out fixes are often the kneejerk reaction. Overtime this becomes a complex inefficient operational management task. Understanding how decisions impact things upstream and downstream are key. Often the quick fix increases work and error potential.

The COVID crisis has exposed how many quick “band-aide” fixes have been deployed. This catalyst is how our team delivers through a unique and methodical approach for ensuring an actual root cause fix.

Revenue Cycle Review

Contract Review

If you have not reviewed your practice contracts with insurance payers in several years, you are leaving much revenue on the table. Ask our team at Oncospark how we can help you with your Contract Negotiations. We have a proprietary database called EvaluPrice, that gives you insight in Price Transparency. Data driven negotiations are critical.

Credentialing

If you are a practice that accepts insurance and files on behalf of your patients, and you do not comply with the process of credentialing you are also leaving much revenue on the table. There are also the patients to consider as they are there to see you because they need your services but if another practice down the street is in network with their plan you may risk losing them to your practice.

You might be thinking that one or two patients may not hurt your bottom line but consider the ripple effect they may have when they tell others or if you live in an area where the major employer in your community offers the one plan you are not in network with. As a patient what would you do? We use a predictive credentialing process, because we understand that what is needed is 3-6 months down the road. Pivoting from a reactive to a proactive approach is necessary.

Prior Authorizations

It’s no secret that facilities and practices are writing off hundreds and sometimes thousands of dollars annually for failing to properly obtain Prior Authorizations. Health plans know that a lot of prior authorization effort is wasted and between 90% and 95% of the care that’s reviewed is eventually approved, and only a handful of orders turn out to be truly inappropriate. This is a systemic problem.

In some specialties as well the medical necessity or lack thereof that is detailed in many policies will make a Pre-Determination necessary. For example, physicians who perform procedures on the breast will find that without the diagnosis of cancer, many procedures may be classified as cosmetic. For the best outcome and to show due diligence, many practices have made the decision to obtain a Pre-Determination for an extra line of defense. Of course, all practices should detail all possible outcomes in their financial policy. The indirect costs of aggravation and burnout among physicians, and of care delays for the patient are paramount. Our team created Authparency for this.

Unbundling

Many practices find that a lot of Denials are due to trying to report two services, one of which is inclusive to another. Coding guidelines are established by the American Medical Association and major insurance carriers like Medicare, Medicaid, United Healthcare, Aetna and Cigna may have their own interpretation on what they feel should be inclusive.

Ignoring these guidelines is costly and leaves you open to an audit risk that could end up with an even greater loss of revenue due to money being taken back from previously paid claims.

It’s important to have a qualified Coding expert on staff or have quarterly/annual audits to keep an eye on the compliance of your claim submission. Hiring more coders is not the answer and often a coders time is better spent somewhere else. Our code interceptor analysis of your service line is step one in creating a more accurate and standardized approach.

Learn more about Code Interceptor

Education

After you have conducted an internal audit or review, you will want to use that data to provide your staff with an education plan. However, how much data did you review? Can you prioritize the results? Can an action plan be developed from the findings? Once identified and training has been deployed, are you able to monitor results and progress?

This is what our Oncospark client partnership is centered around. Our goal is for your staff to perform all tasks. We have models from outsource to insource to supplemented integration. All have the same goal of you maintaining your autonomy of the process.

Contact Jmcnamara@oncospark.com if you would like more information about how we can provide a custom plan for you.

 Credit: Jordan Johnson, Co-Writer

 


 

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